Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Pakistan Says a Clear “No” to Commercial Transplantation
- Farhat Moazam (21 June 2008)
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Renal transplantation in Karachi; we need facts not fables
- Faheem Akhtar, Lahore 54600 Pakistan (4 July 2008)
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Organ Donation : My Point of View
- Maqsood. A. Noorani (9 September 2008)
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Farhat Moazam, Professor and Chairperson Center of Biomedical Ethics and Culture, SIUT, Karachi 74200, Pakistan
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Farhat Moazam, M.D., Ph.D (famoz@mindspring.com) This is in response to M A Noorani’s article “Commercial transplantation in Pakistan” published in BMJ on June 14, 2008. While expressing his views Noorani makes, perhaps inadvertently, statements that do not present an accurate picture of the current situation of kidney transplantation in Pakistan. Noorani states that in his surgical practice in Pakistan, 95% of related donors were women. In the absence of a national registry in Pakistan, Noorani’s experience cannot be generalized as reflecting the donor gender ratio in all institutions in the country. The potential for coercing women to donate organs is undoubtedly a significant issue in many societies and it is the ethical responsibility of transplant physicians to serve as “gate keepers” to prevent this as best as possible. The Sindh Institute of Urology and Transplantation (SIUT) in Karachi, the busiest public sector institution, began kidney transplants in 1985 and uses only organs donated by living family members. It now undertakes over 250 transplants every year and through careful family screening by teams that include female social workers, has managed to maintain an equal male: female donor ratio.(1) Moreover, in a recent study published about vendors in Punjab the majority, for various cultural reasons, are males in contrast to the experience from South India.(2) More importantly, Noorani seems unfamiliar with the organ transplantation law passed by the government of Pakistan as a result of strong pressure by members of the public and healthcare professions opposed to kidney commerce. The Human Organ and Tissue Transplantation Ordinance passed in September 2007, explicitly and unambiguously, makes buying and selling of human organs a crime and prohibits transplantation of organs from Pakistanis into foreigners. These offences are punishable by fines and imprisonment of up to 10 years. Three private hospitals in Punjab are currently under investigation for having transplanted foreigners and others with kidneys from unrelated sources. Citizens of other countries traveling to Pakistan for transplants with kidneys obtained from unrelated donors now run the risk of being prosecuted. Following passage of Ordinance 2007, commercial kidney transplants have come to a near halt, and the government is under public pressure for transparent implementation of the law. Kidney transplantation with organs bought from vendors in countries such as Pakistan exploits the most disadvantaged for the benefit of the privileged, and also carries significant risks for recipients (as Noorani admits). It also reduces altruistic donation and defeats efforts to develop deceased donor programs and achieve national self-sufficiency. The recently updated WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation, and the Asian Task Force Report on Organ Trafficking released in May 2008, clearly declare all forms of organ commerce to be unethical, and recommend that governments establish laws to prevent such practices. It is equally important that governments of all countries, especially the affluent, accept their moral duty to introduce steps that discourage their citizens from indulging in organ tourism that targets countries like Pakistan. In a world with tremendous, and increasing, socioeconomic disparities, this is what global justice demands from all of us. References: 1. Farhat Moazam, Bioethics and Organ Transplantation in a Muslim Society, eds. Eric M. Meslin, Richard B. Miller (Bloomington: Indiana University Press, 2006): 59, 107-121 2. Syed A. A. Naqvi, Bux Ali, et al. “A socioeconomic survey of kidney vendors in Pakistan,” Transplant Int 2007; 20:934-939 Competing interests: None declared |
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Faheem Akhtar, Medical Officer, Health Department Punjab (Pakistan) 7-A Street One, Ghousia Colony, Lahore 54600 Pakistan
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Sir, This is in response to letter “Commercial transplantation in Pakistan and its effects on Western countries” by Dr. Noorani on 14th June, 2008. It was these pertinent assertions about gender and social class of live- related donors (LRD), emphasis on live-related kidney donations instead of cadaveric mode, national transplantation programme, dearth of relevant data, pointing out two opposing vested interests, and a ban on the foreign clients, in a letter to the editor in the daily Dawn on October 18, 2007, that had prompted a reply on the same pages six days later. Rapid Response on 21st June by spokesperson of Sind Institute of Urology and Transplantation (SIUT) retains identical contents although author did not happen to be the same person. It might be their statement for this year, just like their scientific publication of this decade. Only the statement about yearly activity is an add-on. Let me add that Dr. Moazzam`s data does not tally with the ubiquitous global trends. In the absence of reliable statistics, I beg to differ from Dr. Noorani about the given figure of 95% but rest of the statement is perfectly valid, albeit with an empirical support. [1] LRDs will be one of the measures which will help control organ trade in Pakistan. Patient compliance is dependent on the national economic strength and that of the patient’s family. Still, we do need to have a structured national Nephrology Service for exerting a better control. There might be four parties involved because of transplant tourism. International community should not perceive us as an organ sharing nation be it in the form of cadaver donations or living un-related donations (LURDs). Following an intense debate on LURD, a new argument over cadaveric mode of organ donation was stirred up by one of the two groups, days before the promulgation of the Transplantation of Human Organs and Tissues Ordinance 2007 (THOT 2007) unveiling an optimistic Deceased Donor Transplant Programme. [2, 3] This is where financial burden comes into play. Donor Card campaign was a total failure. Only one case of a living will has been carried out by the national media. May I dare ask the protagonists of a cadaver programme as to how many of 1, 6000 registered ESRD patients will be able to finance a kidney transplant? [4] How will be the rest of the organs utilized? Cornea is the only other organ that is transplanted in Pakistan. There is a serious need to project precise data. 250 kidney transplantations per year is an instance of misrepresentation by kidney transplant-related health facilities in Karachi, who as the whole nation is aware, are guilty of imposing a total blackout on statistics on renal transplantation activities in Karachi. [3] I would like the readers to visit http://www.siutna.org/comments.cfm and Paul Garwood’s Dilemma over live-donor transplantation for SIUT’s varied projections. Pardon my candour when I refer to http://www.martinfrost.ws/htmlfiles/mar2008/pak_kidneys.html. What information did Dr. Moazzam offer to the delegates of the Amsterdam Forum earlier this year? My own request to the Director, SIUT for figures on liver transplantation at SIUT remains un-answered. Let me add by informing the readers about the very latest. It is not only the cadaveric donation lobby who want it amended, THOT 2007 has also been challenged by the LURD lobby in the highest court of law, a clear indication that both groups still have a notion of controlling this one- billion dollar market in Pakistan. No wonder that SIUT stands out alone among 35 institutions in Pakistan for not having been granted a permanent recognition by Human Organs Transplant Authority. [5] Another instance of kidney theft involving four persons in Lower Punjab was reported by a local Urdu daily on July 1, 2008. Some respect for the law of the land, professional ethics and truthfulness is warranted. Faheem Akhtar
References: 1- The Nation, Lahore. 90pc of transplant organs donated by women. Available at: http://www.nation.com.pk/daily/mar-2005/8/index12.php. Accessed June 12, 2007. 2- Faheem Akhtar. Backdoor to medical tourism. Daily the Post, Lahore. Editorial comments. December 18, 2007. http://thepost.com.pk/Previuos.aspx?dtlid=134709&src=Faheem%20Akhtar&date=18/12/2007. 3- Akhtar F. Organ transplantation law in Pakistan to curb kidney trade: chance for global reflection. NDT Plus. 2008 1(2):128-129. 4- The Kidney Foundation. Dialysis Registry of Pakistan 2005-2006. Available at: http://www.kidneyfoundation.net.pk/Dialysis%20Registry.pdf. Accessed May 3, 2008. 5- Daily Dawn. SIUT omitted from list of approved transplant institutes. Available at: http://www.dawn.com/2008/03/31/local2.htm. Accessed April 4, 2008. Competing interests: None declared |
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Maqsood. A. Noorani, Consultant General &Transplant Surgeon Marylebone NW1 6AL
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This letter is in connection with the response to my article “Commercial Transplantation in Pakistan” published in the BMJ dated 13 June 2008. The feedback received was mostly positive and I hope it will help the cause of organ donation and save more lives. However, some newspapers did unfortunately misconstrue my meaning. I have always made it clear that I am in strict opposition of the organ trade. In fact, I suggested that donors be compensated by a government controlled programme in order to bring an end to the inhumane organ trade. In the rapid response there were two letters, both from Pakistan. The responses represent two extremes of opinion on transplantation in Pakistan, which are often in conflict. The first group is headed by Prof. Adib-ul Hassan Rizvi, the founder of Sindh Institute of Urology and Transplantation (SIUT) and his associates, representing the public sector. The other is headed by retired Brigadier surgeon and his colleagues, representing the private sector. Prof Rizvi, the pioneer of transplant in the public sector in Pakistan is of the opinion that transplants should only be performed from favourably matched first blood donors (siblings and parents). He is the main architect of the recent ordinance to allow cadaveric donation. The other group supports paid organ donation to locals and foreigners. They believe it helps the recipients and provides financial relief to poor donors and that it also helps the country by bringing in foreign exchange (one billion dollars market according to Dr Faheem Akhtar’s letter in the Rapid Response Section). This group also believes that at present, it is too expensive and strategically unfeasible to establish a cadaver donation program in Pakistan. My article presented a middle of the road program as far as Pakistan is concerned. The socio-economical situation and religious and cultural values in Pakistan are different from the west. Feudalism is still integral to society and women have virtually non-existent rights. The literacy rate remains miserable. The recent oil crisis, war in Afghanistan, Talibanisation, judicial crisis and political vacuum after the assassination of Benazir Bhutto has brought the country to the brink of disintegration. In such a society, the survival of the fittest and the law of necessity dictate the day-to-day life of the people. In Pakistan or for that matter any country, where there is political and economic instability, poverty and corruption invariably control the system and the poor are desperate to earn a living to support their families, often at the expense of their own lives. At present the poor are selling their kidneys, but with the dire straits the country is in currently, one can envisage the day that they shall be selling parts of their intestine, lung and liver. The visage of transplantation in Pakistan has been changed by the recent promulgation of the transplantation ordinance in 2007. This is yet to become a law, though it is certainly a step in the right direction. The main aim of the ordinance is to stop commercial transplantation. It did initially succeed to control it, but because of certain flaws in the ordinance, the trade in organs even to foreigners continues to prosper. Considering that Pakistan is a country where people have large extended families, traditionally living under one roof, it is surprising that this law does not include first cousins, uncle, aunts and grandparents as blood relatives thus reducing the chances of the recipient to have a donor from within the family. However, even more bizarrely it includes a spouse as a ‘blood relative’ from whom donation is legal. It is worth mentioning here that in Pakistan, a man can marry four wives at one time and on divorcing his wife, he just has to pay a pre-fixed nominal amount. Hence, this clause was always open to exploitation in a country where women have rights that are virtually non-existent. In fact there are reports of middlemen showing female donors as wives by acquiring a back dated marriage certificate for the purpose of donation. A post-dated divorce certificate is very conveniently acquired after the process of donation is complete. As mentioned in my article, in my experience whenever donations are from the first blood relatives or spouse, the donor was invariably of a female gender. In Asian society, especially in a Pakistani setup, women are mostly treated as personal property. Hence donation from female folk of the family in this part of the world should be viewed with caution. I also believe that the philosophy of altruism and coercion in the contest of organ donation needs to be re-examined in general and for third world countries in particular. The concept of always accepting family donors as altruists can be challeged. Despite of extensive and exhausting investigations to prove that the donation is altuistic, an element of coercion may always remain. In my opinion true altruism can only exist when there is no emotional or moral pressure on the donor. Siblings, children and spouses may have some element of moral duty and obligation with regards to donation rather than altruism and the two need to be differentiated. In contrast, the situation in the western world is of stark contrast. The literacy rate is close to one hundred percent. People, especially women are aware of their rights. Everyone is provided with the basic needs for living, the governments are stable and most importantly there is rule of law. Under such circumstances it is impossible to exploit even the poor for organ donation as they are protected by the government and above all the law. The UK Transplant, the British Transplant Society, the transplant teams and other organizations have done a wonderful job during the last seven years and have certainly achieved great results. Despite of an increase in the number of live donations and the number of transplants, the number of patients registered on the active transplant list at 31 March 2007 for a kidney or kidney and pancreas transplant has increased by 43% since 1998. The number of patients registered for kidney and kidney and pancreas transplants increased from 5863 to 6480 from the end of March 2006 to March 2007. This has resulted in an increase in the number of deaths of patients waiting for a transplant. In my article, I had put forward a few suggestions to meet these challenges. Everyone will agree that the only way to tackle the shortage of the organs at present is to increase the number of donations both, live and cadaveric and this can be achieved by the following: a) Increasing the number of live related donations : This can be done by making more efforts to motivate the families of the patients, especially in ethnic minorities. According to the Data from the UK transplant the organ donation in ethnic minorities is almost negligible (6 (1.0%) in 2006 and 8 (1.3%) in 2007), compared to the local population, and at the same time the organ requirement in ethnic minorities is higher compared to the local white population. This can be achieved by advertising that the donation is very safe and that the transplant results are excellent. In addition these donors must be appreciated as heroes and appropriately rewarded and every effort should be made to make the donation process easy and smooth. In addition the transplant community as a whole with special reference to surgeons and coordinators should be rewarded proportional to their efforts to increase enthusiasm and awareness. b) Increasing the number of cadaveric donations: This can be done on an opt out rather than an opt in basis and also by convincing the families especially in the ethnic minorities that by removing the organs from a brain dead or non heart beating person does not result in harm or desecration to the departed soul. Moreover the tissue type of the local population is different from the ethnic minorities. Hence unless there are cadaveric donations from ethnic communities, they will continue to struggle to receive organs for transplantation. This can be achieved by using the services of the local GPs, counsellors, clergy and MPs. c) Legalizing the un-related voluntarily donation based on government controlled compensation program: Unfortunately the number of these donations at present is limited, and unless some initiatives are taken by the government the number will not rise. This can be in the form of appreciation by awarding certificates and medals of honour for saving the life of fellow citizens. It can also be in terms of compensation for the lost wages and life insurance should the donor suffer any donor related complications. In addition priority in NHS appointments, medical insurance and free/discounted transport may be other avenues to explore. Prof. M. A. Noorani Competing interests: Transplantation Organ Donation |
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